management of acute poisoning
DESCRIPTION
MANAGEMENT OF ACUTE POISONING. Kent R. Olson, MD Medical Director California Poison Control System San Francisco Division. Lessons from history. A young princess ate part of an apple given to her by a wicked witch She was found comatose and unresponsive, as if in a deep sleep - PowerPoint PPT PresentationTRANSCRIPT
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MANAGEMENT OF ACUTE POISONING
Kent R. Olson, MDMedical Director
California Poison Control System
San Francisco Division
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Lessons from history
A young princess ate part of an apple given to her by a wicked witch
She was found comatose and unresponsive, as if in a deep sleep
Airway positioning and mouth to mouth ventilation were performed, and she recovered fully
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Lesson:
Best antidote is good supportive care
(Love’s first kiss)
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Case 1:
Young woman found unconscious, several empty pill bottles nearby
Unresponsive to painful stimuli Shallow breathing
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Initial management: ABCDs
Airway Breathing Circulation Dextrose, drugs, decontamination
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Airway issues
Risks:• Floppy tongue can obstruct airway• Loss of protective reflexes may permit
pulmonary aspiration of gastric contents
Major cause of morbidity in poisoned patients
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Assessing the airway
“Gag” reflex• Indirect measure• May be misleading• Can stimulate vomiting
Alternatives
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Breathing
Assess visually pCO2 reflects ventilation - ABG useful pulse oximetry provides convenient,
noninvasive evaluation of O2 saturation
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Pitfalls
pO2 measures dissolved oxygen• can be normal despite abnormal
hemoglobin states, eg COHgb, MetHgb
Pulse oximetry also fails to detect CO poisoning
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Interventions
Endotracheal intubation• Protects airway• Allows for mechanical ventilation
Reverse coma?• Naloxone: note T½ = 60 min• Flumazenil?
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Don’t forget GLUCOSE
“A stroke is never a stroke until it’s had 50 of D50” – Dr. Larry Tierney, 1976
• “Well, you could just do an Accuchek”- ibid, 2002
Give Thiamine 100 mg IM or in IV
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Case, continued…
The patient has no gag reflex, and does not resist intubation.
She remains unconscious and on a ventilator overnight
Awakens and extubated the next day Dx: mixed sedative drug overdose
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Case 2
47 year old man calls 911, suicidal BP 70/50, HR 50/min Junctional rhythm Hx: uses an antihypertensive
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Circulation = plumbing
Pump working? Enough volume (is it primed)? Adequate resistance (no leaks)?
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Management of Hypotension
Hypovolemia?• IV fluid challenge
Pump?• Dopamine
Inadequate vascular resistance?• Norepinephrine, phenylephrine
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Antihypertensives
Diuretics Beta blockers Calcium channel blockers ACE Inhibitors Centrally acting agents Vasodilators
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Calcium channel blockers
Bad ODs!! Low Toxic:Therapeutic ratio High mortality
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Negative InotropicEffects
Negative InotropicEffects
DecreasedAutomaticity& Conduction
DecreasedAutomaticity& Conduction
Dilated VascularSmooth Muscle
Dilated VascularSmooth Muscle
SVRSVRCOCOHRHRAV BlockAV Block
SHOCKSHOCKSHOCKSHOCK
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Calcium antagonists - treatment
Calcium: most effective• High doses may be needed
Glucagon – variable results Insulin plus glucose? (experimental)
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Case 3:
An 18 month old takes some of his grandmother’s “sleeping pills”
Brought to the ER after a seizure HR 150/min Pupils dilated, skin flushed, mucous
membranes dry
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Common causes of seizures
Amphetamines/cocaine Tricyclic and other antidepressants Isoniazid (INH) Diphenhydramine Alcohol withdrawal Many others . . .
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30 minutes later, the ECG shows:
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Tricyclic antidepressants
Anticholinergic syndrome Seizures Cardiotoxicity
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TCA overdose treatment(similar tox possible w/ massive diphenhydramine)
Stop the seizures• Benzodiazepines, phenobarbital
Treat cardiotoxicity• Sodium bicarbonate 1 mEq/kg IV• IV fluids• Dopamine and/or NE
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Case 4: metabolic acidosis
Young man had a seizure at home In ED: obtunded, another seizure pH 6.94, pCO2 32 Recent immigrant, lives with extended
family Uncle being treated for TB
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Metabolic Acidosis: MUDPILES
Methanol Uremia DKA Phenformin (whaa?) Isoniazid, Iron Lactic acidosis Ethylene Glycol Salicylate
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Isoniazid overdose
Reduces brain pyridoxal 5-phosphate, a cofactor for glutamic acid decarboxylase:
Seizures common; acidosis often severe Antidote: Pyridoxine (Vitamin B-6)
GlutamateGlutamate GABA GABA GAD
(excitatory) (inhibitory)
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Case 5: another acidosis
44 year old man, obtunded BP 110/80 HR 110 RR 24 pH 7.47 pCO2 22 pO2 92 Na 140 K 3.8 Cl 104 HCO3 18 EtOH 0.18 gm/dL (180 mg/dL)
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Salicylate poisoning
Typical mixed acid-base disturbance• Respiratory alkalosis• Metabolic acidosis
Large OD or enteric coated tablets may delay peak level
Treatment: • Urinary alkalinization, hemodialysis
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Case 6: more acidosis
30 yo woman found comatose T 92 F, pH 6.9 Na 147, K 4.9, Cl 105, Bicarb 5 (AG 37) Glucose 166, BUN 16, Cr 1.5 Measured Osm 331 (calculated 308) EtOH: none detected
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The Osmolar Gap
Common causes of Osm Gap:• Ethanol• Methanol & Ethylene Glycol• Other alcohols, also aldehydes, ketones
Osm = 2 (Na) + BUN/2.8 + Glucose/18
Gap = Measured - Calculated Osm = 0 + 5
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METHANOLMETHANOL
FORMALDEHYDEFORMALDEHYDE
FORMIC ACIDFORMIC ACIDANION GAPACIDOSIS
ANION GAPACIDOSIS
ELEVATEDOSMOLAR GAP
ELEVATEDOSMOLAR GAP
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Methanol or Ethylene Glycol:
Elevated Osm Gap Anion gap
• Low lactate, does not account for gap• Anion gap may be absent early after OD
Other clues (may be unreliable):• Methanol: blindness, visual disturbance• EG: urine crystals, fluorescence
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Methanol or Ethylene Glycol:
Main DDx: alcoholic ketoacidosis• Anion and Osm gaps• Low lactate
Clues to AKA:• Gets better quickly w/ IV fluids, dextrose• [Ketones] +/- (mainly -hydroxybutyrate)
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Case 7: now we’re cookin’
24 year old man with Hx depression Agitated, confused BP 110/70 HR 120 RR 20 T 40.4 C Muscle tone increased, LE clonus Tox screen negative for cocaine,
amphetamines
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Drug-induced Hyperthermia
Heat Stroke Malignant Hyperthermia Neuroleptic Malignant Syndrome Serotonin Syndrome
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Drug-induced “heat stoke”
Altered judgment leads to excessive sun/heat exposure
Anticholinergic drugs prevent sweating
Excessive muscle hyperactivity from seizures, or from extreme agitation
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Malignant hyperthermia
Rare, familial myopathy Triggered by general anesthesia
• Succinylcholine• Inhalational agents (eg, Halothane)
Muscle rigidity, hypermetabolic state Treatment: dantrolene
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Neuroleptic Malignant Syndrome
Patient on dopamine-blocking drugs • Haloperidol classic cause• Also with newer agents (eg, clozapine)
Rigidity (lead-pipe) Autonomic instability Hyperthermia
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Serotonin Syndrome
Current “hot” diagnosis Serotonin-enhancing Rx
• SSRIs in OD or multiple combos• MAOI + serotonin-ergic drug
Hypertonicity/clonus (esp. lower extr.) Autonomic instability Hyperthermia
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Hyperthermia treatment Act quickly!
• Remove clothing spray and fan• Sedation and anticonvulsants PRN• Neuromuscular paralysis if T >40 C• Dantrolene if NM paralysis ineffective• Consider bromocriptine, cyproheptadine
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One more common one
A 17 year old boy takes a bottle of “aspirin” after he gets his SAT score
Next morning, he is vomiting In the ED, normal vital signs Aspirin (salicylate) = negative
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Acetaminophen
Very common overdose May be overlooked
• “It’s just aspirin” (OTC’s can’t kill you..?)• Hidden ingredient in many drug combos• No specific findings after OD• Delayed illness/lab abnormalities
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Acetaminophen (APAP)
Glucuronidation(non toxic)
Sulfation(non toxic)
NAPQI
P-450
~ 5%
Glutathione + NAPQInontoxic product
Liver cell damage
NAC
++
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N-acetylcysteine (NAC) Start within 8 hrs if possible Vomiting often interferes w/oral
dosing• Antiemetics (ondansetron, etc)• Can dribble in by NG tube
IV form now available (Acetadote™)• Caution: hypotension w/rapid infusion
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Gut decontamination after OD
Goal: reduce systemic absorption• Induce vomiting?• Pump the stomach?• Activated charcoal
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Ipecac-induced emesis
Easy to perform, butnot very effective
Contraindicated:• Comatose/convulsing• Ingested corrosive or hydrocarbon
Bottom line: nobody uses it anymore
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Pumping the stomach
Cooperation not required MD sense of
“control” Punitive value?
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Gastric lavage
May stimulate gagging, vomiting Risky if airway reflexes dulled Lack of proven efficacy Bottom line: used only rarely
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Activated charcoal
Finely divided powdered material• Huge surface area
Binds most drugs/poisons• Exceptions:
• Lithium• Iron
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Activated charcoal
More effective than SI, GL First choice for most ODs
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Whole bowel irrigation
Mechanical flush Balanced salt solution with PEG
• No net fluid gain/loss Good for:
• Iron• Lithium• Sustained-release pills,
foreign bodies
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Antidotes:
The best antidote is supportive care Examples of antidotes:
• Digoxin-specific antibodies• Atropine & 2-PAM• N-acetylcysteine• Vitamin B-6 (pyridoxine)
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Call the Poison Center
1-800-222-1222 - 24 hours Immediate consultation by
clinical pharmacists Back-up by MD toxicologists Identify pills, discuss diagnosis & Rx
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“I don’t think we should go up there, especially without a paddle”